Acne is an illness that afflicts adolescents and young adults. It has severe psychosocial consequences. About 20% of those with acne who seek medical care are severe enough to require systemic therapy. Based on NHANES, data about 2 million people per year are in this category, and they account for 5 to 6 million physician office visits per year. According to IMS, about 9.7 million prescriptions are written for oral and about 8.2 million prescriptions are for topical antibiotic therapy for acne yearly. Furthermore, the topicals are used as first line therapy 58% of the time and the orals 40% of the time. Therapy frequently continues for more than 6 months. Simply stated, very large quantities of antibiotics are used for an extended period of time by this sector of the population. GAS is an important public health issue in that it is the main bacterial cause for the more than 200 million cases of upper respiratory tract infections in the USA per year and the main reason to treat these cases with an antibiotic. The economic cost to the US alone is more than 25 billion dollars per year.
Individuals with acne are generally healthy patients often exposed to antibiotics for prolonged periods of time. It is believed that appropriate but long-term use of antibiotics by patients and physicians has played a role in the development of organisms that are now resistant to multiple antibiotics. Importantly, these changes are not always permanent. For example, reductions in the use of antibiotics have been shown to result in subsequent decreases in bacterial resistance of such organisms as Streptococcus pyogenes (Seppala H, Klaukka J, Vuopio-Varakila A et al and the Finnish Study Group for Antimicrobial Resistance. The effect of changes in the consumption of macrolide antibiotics on erythromycin resistance in group A streptococci in Finland. N Engl J Med 1997; 337:441-446; York M K, Gibbs L, Perdreau-Remington F, Brooks G F. Characterization of antimicrobial resistance in Streptococcus pyogenes isolates from the San Francisco Bay area of Northern California. J Clin Micro. 1999; 37:1727-1731). Tetracyclines and erythromycin are two antibiotics commonly used in dermatological practice for the long-term treatment of acne vulgaris (Espersen F. Resistance to antibiotics used in dermatological practice. Br J Dermatol. 1998; 139:4-8). Studies have shown that Propionibacterium acnes and coagulase-negative staphylococci quickly develop resistance to these antibiotics (Leyden J J, McGinley K J, Cavalieri S, Webster G F, Mills P H, Kligman A M. Propionibacterium acnes resistance to antibiotics in acne patients. J Am Acad Derm. 1983; 8:41-45; Marples R R, Kligman A M. Ecological effect of oral antibiotics on the microflora of human skin. Arch Derm. 1971; 103:148-153), which may result in therapeutic failure and the propagation of resistance to bacteria in the skin (Miller Y W, Eady E A, Lacey R W, Cove J H, Joanes D N, Cunliffe W J. Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts. J Antimicrobiol Chemother. 1996; 38:829-837) and gastrointestinal flora of close contacts (Adams S J, Cunliffe W J, Cooke E M. Long-term antibiotic therapy for acne vulgaris: effects on the bowel flora of patients and their relatives. J Invest Derm. 1985; 85:35-37). While the effects of long-term antibiotic use on cutaneous microbial environments in this patient population have been well studied, the effects of antibiotic use on non-cutaneous surfaces, such as the oro-pharynx, which could be a source of systemic illness, have not.
The injudicious use of antibiotics has been a public health concern for many years; as recently reinforced by a study on the potential association between antibiotics (including those used to treat acne) and breast cancers. Antibiotic drugs select for resistant bacterial pathogens and eliminate normal host flora, resulting in colonization and infection with drug-resistant pathogenic organisms. Fortunately, these changes are not always permanent. For example, stopping antibiotic use has been shown to result in both the subsequent resurgence of the sensitive organisms and the return of normal flora. While public health experts have frequently blamed this disturbing trend on injudicious antibiotic use, it should be noted that this phenomena can happen with appropriate antibiotic prescribing by physicians and, by patients, using antibiotics as recommended.
Acne vulgaris is a disease for which long-term antibiotic use is standard and appropriate therapy. However, the burden of both acne and acne therapies, as with all skin diseases, on society and the patient has not been well described (http://www.niams.nib.gov/ne/reports/sci_wrk/2002/Burden_skin_disease_MAIN.htm). Therefore, there is a need for effective treatment for Acne that will not be burdensome on society and the patient.